Print

Date Printed: June 23, 2017: 11:38 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-92000-21

Original Effective Date: 04/15/02

Reviewed: 02/22/10

Revised: 11/01/15

Subject: Photocoagulation of Macular Drusen

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

Age-related macular degeneration (AMD) is a painless, insidious process. In its earliest stages, it is characterized by minimal visual impairment and the presence of large or soft drusen. Drusen are tiny yellow deposits in the retina (subretinal accumulations of cellular debris adjacent to the basement membrane of the retinal pigment epithelium). One of the most common early signs of AMD is the presence of drusen. The presence of drusen alone does not indicate AMD, but may mean a risk for developing AMD.

Large drusen appear as large pale yellow or pale gray domed elevations. Large drusen results in thickening of the space between the retinal pigment epithelium and its blood supply (choriocapillaris). Clinical and epidemiologic studies have shown that the presence of large and/or numerous soft drusen increase the risk of the development of choroidal neovascularization (CNV) in eyes with AMD. The emergence of CNV greatly increases the risk of subsequent irreversible loss of vision.

Argon and infrared laser are two different kinds of low energy laser therapies that have been investigated as techniques to eliminate drusen. These low energy laser therapies use photocoagulation to prevent CNV. The lasers used are the lasers used for standard photocoagulation of extrafoveal choroidal neovascularization. The treatment of macular drusen represents an additional indication for an existing laser approved by the U.S. Food and Drug Administration (FDA).

POSITION STATEMENT:

Destruction of macular drusen with laser therapy as a prophylactic treatment to prevent progression of choroidal neovascularization (CNV) is considered experimental or investigational, as clinical data has not shown this treatment to be effective, and may actually cause harm.

BILLING/CODING INFORMATION:

There is no specific CPT or HCPCS code to report photocoagulation of macular drusen.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services (L29288) located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Verteporfin (Visudyne™) Injection, 09-J1000-72
Transpupillary Thermotherapy (TTT), 01-92000-20

OTHER:

Other names used to report photocoagulation of macular drusen:

Drusen Laser Therapy
Laser Photocoagulation of Drusen
Laser Therapy Macular Drusen
Macular Drusen Destruction

REFERENCES:

  1. American Medical Association (AMA) Current Procedural Terminology (CPT), 2007.
  2. Blue Cross Blue Shield Association Medical Policy Photocoagulation of Macular Drusen (9.03.11), 11/20/01, updated (06/12/08).
  3. Blue Cross Blue Shield TEC Special Report: Current and Evolving Strategies in the Treatment of Age-Related Macular Degeneration, Vol. 20 No. 11, 01/06.
  4. Florida Medicare Part B Local Coverage Determination for The List of Medicare Non-covered Services (L29288). 02/02/09. Updated 12/22/09.
  5. Clinical Trials.gov. Complications of Age-Related Macular Degeneration Prevention Trial (CAPT), 2006. Accessed (01/30/08).
  6. Complications of Age-Related Macular Degeneration Prevention Trial Research Group. Laser Treatment in Patients with Bilateral Large Drusen: The Complications of Age-Related Macular Degeneration Prevention Trial. Ophthalmology 2006; 113(11): 1974-1986.
  7. First Coast Service Options, Inc. (FCSO) Local Coverage Determination Noncovered Services (L29288), 02/02/09.
  8. Folk JC, Russell SR. Can Laser Photocoagulation of Eyes with High-Risk Drusen Prevent Vision Loss From Age-Related Macular Degeneration? Ophthalmology 1999; 106(7): 1241-1242 [Editorial].
  9. Food & Drug Administration, Health & Human Services News Release, FDA Approves Treatment For Wet Macular Degeneration, 04/13/00.
  10. Friberg TR. Prophylactic Treatment of Drusen in AMD. Review of Ophthalmology: October 2001. Accessed 02/06/07.
  11. Hayes Technology Brief. Laser Photocoagulation of Macular Drusen as a Prophylaxis Against Progression of Age-Related Macular Degeneration (12/31/07).
  12. Laser Treatment in Fellow Eyes with Large Drusen: Updated Findings from a Pilot Randomized Clinical Trial. Ophthalmology. 2003; 110 (5): 971-978.
  13. National Eye Institute-Age-Related Macular Degeneration, 04/06. Updated 09/09.
  14. Owens SL, Bunce C, Brannon AJ et al. Prophylactic Laser Treatment Hastens Choroidal Neovascularization in Unilateral Age-Related Maculopathy: Final Results of the Drusen Laser Study. American Journal of Ophthalmology 2006; 141(2): 276-281.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/22/10.

GUIDELINE UPDATE INFORMATION:

04/15/02

New Medical Coverage Guideline.

05/15/03

Annual review.

05/15/04

Changed guideline number from 01-91000-21 to 01-92000-21.

06/15/04

Scheduled review, no changes.

03/15/05

Scheduled review, no change in coverage statement.

03/15/06

Added information regarding the treatment of macular drusen with an U.S. FDA approved laser to the description section. Added Laser Photocoagulation of Drusen to other section. Updated references.

03/15/07

Scheduled review, no change in coverage statement. Updated references.

06/15/07

Reformatted guideline.

03/15/08

Scheduled review; change in position statement. Update references.

03/15/09

Scheduled review; no change in position statement.

03/15/10

Scheduled review; no change in position statement. Update references.

12/15/10

Unscheduled review; revised position statement to reflect that photocoagulation of macular drusen (0017T) is considered experimental or investigational (versus the previous verbiage of “not medically necessary”).

01/01/11

Annual HCPCS coding update. Deleted code 0017T.

02/15/14

Revision; Program Exceptions section and references updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: June 23, 2017: 11:38 AM